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TB DILI Bridging Regimen — SCE Infectious Diseases MCQ

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ModerateTuberculosisTB DILI Bridging RegimenSCE Infectious Diseases

A 55-year-old man with TB develops hepatitis (ALT 650 U/L, bilirubin 45 µmol/L) at week 3 of treatment. All hepatotoxic drugs (Isoniazid, Rifampicin, Pyrazinamide) are stopped. He is left on Ethambutol only. LFTs improve over 2 weeks. What bridging regimen can be used while hepatotoxic drugs are being reintroduced?

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Correct answer: D — Ethambutol plus a Fluoroquinolone (Moxifloxacin or Levofloxacin) ± Streptomycin — to maintain TB treatment while hepatotoxic drugs are sequentially reintroduced

During drug-induced hepatitis from TB treatment, a bridging regimen (Ethambutol plus a Fluoroquinolone ± injectable) maintains TB coverage while hepatotoxic drugs are stopped and sequentially reintroduced. The standard reintroduction order: Rifampicin first (most important drug, intermediate hepatotoxicity risk) → Isoniazid second → Pyrazinamide last (most hepatotoxic — often not rechallenged, extending treatment to 9 months). Each drug is reintroduced at full dose with LFT monitoring every 3 days. Never reintroduce all drugs simultaneously.

Reference: NICE NG33 2016 – TB; BTS 2024 – TB hepatotoxicity; ATS/IDSA 2003